Reducing attendance and waits in A&E departments: A review and survey of present innovations
Project schedule: September 2002 to August 2003
Undertaken by Emergency care research group at University of Warwick

Background

Plan

Aims

Methodology

Dissemination

Background

Improving the quality of emergency care, in particular reducing waiting times in A&E, is a government priority. Excessive waiting is the commonest cause of complaints in an A&E department. The Audit Commission recently highlighted both the delays to see a doctor and to be admitted that presently occur and indicated that these appear to be deteriorating[i]. Many studies have shown that patients in A&E can often be dealt with more appropriately in other environments or by new ways of working[ii][iii][iv]. Reducing waits may improve patient satisfaction[v], and may result in better clinical outcomes and better use of resources[vi]. Waiting time in A&E has many components (e.g. total time in A&E, wait to see a doctor, wait for results, wait for admission,“trolley wait”). Research from our group and others has shown that there may be significant potential for reducing these waits[vii].

The NHS Plan has established targets for waiting in A&E departments, but these will be challenging to achieve. The government strategy, Reforming Emergency Care[viii], launched in 2001, has proposed ways in which these might be achieved through specific changes in A&E and adopting a whole systems approach. The government strategy also focuses on the issue of providing emergency care in the right place at the right time. The A&E Modernisation Programme, commenced in 1999, invested £115m in A&E departments but was not evaluated; Reforming Emergency Care invested a further £100m. There is planned further major investment in NHS emergency care, but the evidence base on which to guide such investment remains weak.

Although many studies have looked at various aspects of the emergency care system, most have been of small-scale and few have been conducted according to rigorous criteria. In part, this reflects the difficulty of undertaking research in emergency care settings, where the organisational context and the immediate priorities related to patient care are often not conducive to the requirements of research. There is no recent comprehensive review available to managers and clinicians which appraises the evidence on all innovations that could reduce attendance at A&E and waiting times. Information on reducing waits in emergency care is also available from the Warwick research teams emergency care lead toolkit.

This study will review the evidence for interventions aimed at reducing any of the components that contribute to waiting times in A&E. Interventions that result in reduction in A&E attendances might allow resources in A&E to focus on reducing waits. Reduction in attendance may occur as a result of changes that prevent attendance at A&E (e.g. GPs referring direct to a specialty consultant, ambulance service links[ix]) or facilitate discharge (e.g. through appropriate social care).

Advisory Group

Warwick university emergency care research group has a standing reference group with representation from users, government and NHS strategy teams, professional organisations and emergency care providers, in both social and health care.

Plan of investigation including research methodology used

The review will focus on studies that have an outcome measure of waiting time in A&E or reductions in attendances there.

Aims of the study

  • To establish the evidence for initiatives to reduce waiting times in and attendance at A&E.
  • To collect vignettes of such initiatives, with commentary of difficulties encountered and solutions

Detailed systematic review methodology

The systematic review will be conducted in accordance with the guidance from the NHS Centre for Reviews and Dissemination at York.The project team will establish clear search strategies, inclusion criteria, criteria for the assessment of relevance and validity, and procedures for the extraction of data and its synthesis. The precise details will have to be refined as part of the project.

The planning group will identify the characteristics of primary studies, which will provide relevant information and valid answers. These will be characterised into eligibility criteria, typically defining (1) the nature of the interventions, (2) characteristics of the participants, setting and referral process, (3) acceptable outcome measures, and (4) acceptable study designs. The eligibility criteria will be piloted on a set of test papers before they are committed to the protocol.

The decision as to what study designs will be eligible will take into account the types of study that have been published according to a standard hierarchy of evidence (see below). An initial search of Medline found 111 papers. The review needs to be inclusive in order to highlight areas where future research may benefit whilst ensuring a systematic approach to discriminate levels of evidence.

A multi-faceted approach will be taken to the search strategies in order to identify all relevant studies for each of the questions suing :

Electronic Database Searching

e.g Medline, EMBASE, The Cochrane Library, NHS Database of Abstracts of Reviews of Effectiveness, The NHS Database of Economic Evaluations. The bibliographies of these articles will be checked to identify further eligible studies. The process will be repeated until no new articles are found.

Manual Searching

Internet Searches

Consultation with other Researchers

Assessment of Eligibility

All articles will have waiting time in A&E or attendance numbers at A&E as an outcome measure.

Assessment of Validity

Selected papers will be graded according to their validity according to predefined hierarchies of evidence.

In addition, the quality of the study within this hierarchy will be evaluated according to standard checklists. These will assess generalisability of the study, applicability to the UK and trial validity..

Meta analysis

Meta analysis will be undertaken if sufficient trials of adequate quality are discovered.

A conference of the advisory board and other experts will be held on September 11th 2003 [INSERT LINK] to present results to a wide audience of experts, policy makers, and service planners and obtain their feedback. This feedback will be included in the final report and contribute to the recommendations for further research

Outputs

A report will be issued in traditional book format and on CD in October 2003. It will also be available on the project website at Papers will be submitted to peer review journals and appropriate scientific and professional meetings.

1

[i] Acute Hospital Portfolio: Review of National Findings - Accident and Emergency. Audit commission 2001. London.

[ii] Browne G. Lam L. Giles H. McCaskill M. Exley B. Fasher B. The effects of a seamless model of management on the quality of care for emergency department patients. Journal of Quality in Clinical Practice. 20(4):120-6, 2000 Dec.

[iii] Grouse A. Bishop R. Non-medical technicians reduce emergency department waiting times. Emergency Medicine. 13(1):66-9, 2001 Mar.

[iv] Lindley-Jones M. Finlayson BJ. Triage nurse requested x rays--are they worthwhile?. Emergency Medicine Journal. 17(2):103-7, 2000 Mar.

[v] Trout A. Magnusson AR. Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say?. Academic Emergency Medicine. 7(6):695-709, 2000 Jun.

[vi] Derlet RW. Richards JR. Overcrowding in the nation's emergency departments: complex causes and disturbing effects. Annals of Emergency Medicine. 35(1):63-8, 2000 Jan.

[vii] Coats TJ. Michalis S. Mathematical modelling of patients flow through an accident and emergency department. Emergency Medicine Journal. 18(3):190-2, 2001 May

[viii] Reforming Emergency Care, Department of Health 2001, London.

[ix] Anantharaman V. Swee Han L. Hospital and emergency ambulance link: using IT to enhance emergency pre-hospital care. International Journal of Medical Informatics. 61(2-3):147-61, 2001 May